Big Pharma

Well, not about HPV, just the vaccines. Actually, not just the vaccines: pretty much everything I heard at a day-long SOGC workshop with the long-winded title, “Women and their Reproductive Health Across the Continuum: Setting Priorities for Women’s Reproductive Health Research”. Attending were both health professionals and interested individuals. And me: women’s health advocate and HPV vaccine skeptic.

Regarding the latter, I waited till the very end of the day to finally screw up my courage.

“I am about to state a very unfavorable opinion. There are reputable health professionals who are opposed to mass HPV vaccination; in part, because some of the research has been tainted by conflict of interest; and also because of the way public messaging has stigmatized parents who have decided not to vaccinate their children.”

I added that equating infection prevention and cancer prevention is what has made public health and Big Pharma messaging so compelling to the general public.

There was absolutely no response.

The Sunnybrook Hospital meeting space was set up like a dinner party, with long lines of tables, labelled with discussion topics for the afternoon. Speakers’ topics were preceded by the title, “State of the Evidence”: Human Papillomavirus, Fertility, Contraception, Menopause and The Environment. Three out of five talks set my teeth on edge.

First up, Dr. Nancy Durand.

After giving some basics about HPV types and statistics (10 – 30% of adults are infected at any given time – good one) and the risks for persistence (being over age 30, smoking, having multiple sub-types and immunosuppression) she launched into straight into HPV vaccines as public health strategy.

Dr. Durand assumed, correctly, that she had the room in terms of the evidence she presented on the three available HPV vaccines regarding efficacy and safety. She said that doctors should treat these vaccines like flu shots and encouraged doctors to say, “Have you had your HPV shot yet?” She suggested it could be administered to babies with their childhood vaccines. She quoted research that indicated there should be no upper limit in vaccinating; and that even if one had already been infected, vaccination was still effective (first time I’d heard that). And yet…

Hello from the other side

My electronic files are full of evidence of conflict of interest (COI) between researchers and pharmaceutical companies and the attempts to expose them.

Moreover, the accepted medical evidence also insists that the only adverse side effects are irritation at the site of injection and increased fainting.

Dr. Heather Shapiro did not mention potential environmental causes of infertility. When I asked her about this, she said that was a whole other talk. She leapt into Assisted Reproductive Technologies starting at IVF without passing through less invasive techniques like IUI. I did find out that 90% of IVF babies are healthy; and the rates of success decline with age; and that there are now fewer multiple births. Her talk was less about fertility and infertility that assisted reproductive technologies. One presumes the research is directed towards treatment rather than prevention. No mention of Pelvic Inflammatory Disease.

Contraception

I was glad to hear Dr. Dustin Costescu discuss unintended births in the context of the social determinants of health. He said they occurred more often in younger, racialized, poor and Indigenous women; and that the greatest risk was due to systemic factors. Among the contributors to non-use were being a sexual or gender minority, funding, and failure to initiate contraception. He also blamed health care providers who sometimes recommended a “washout”; i.e., stopping a method to see if side effects subsided without offering a replacement method.

He pointed out changing trends. With women having their first child around age 30, they require about 11 years of contraceptive use.

I was glad to hear him say that researchers needed to understand women’s experience through qualitative research regarding access, counselling, decision making and understanding side effects. In our discussion session in the afternoon, he acknowledged that front-line workers have a lot to contribute to research. Here are some of my contributions in WordPress:

Menopause

Any of the women attending who had not already gone through menopause and were listening to Dr. Jennifer Blake were probably bug-eyed looking at the list of what sounded like inevitable symptoms. Early on in her talk, she said that perimenopause, the 2 – 3 years preceding the cessation of menses, was the “best time to get help”. Now if that isn’t a clear medicalization of menopause, I don’t know what is.

Dr. Blake was quite definitive. The “pleats” that make women’s vaginas stretch more easily smooth out. You’re going to shrink, was the message. Not to mention the loss of bone mineral density, the release of lead stored in the bones, changes in blood vessels, changes in abdominal fat metabolism, decreased carbohydrate tolerance, loss of lean muscle mass, vasomotor symptoms (hot flashes that could last up to 20 years), mood changes, reduced stress tolerance and memory changes (or as comedian Sandra Shamas tells us, loss of nouns.

And, oh, yes, loss of libido. I’ve had a few thoughts on that one as well.

Dr. Blake gave a nod to the importance of exercise and good nutrition before moving ahead with hormone therapy (HT), “the single most effective treatment”. She spent a good deal of time discussing the history of research on the effects of estrogen, in particular, how the Nurses’ Health Study was written and interpreted. One telling statement at the end of her remarks on HT: “there is a higher risk of breast cancer with later pregnancy than with hormone therapy”. In other words, you don’t need to worry about using HT.

Not all women experience menopause the same way – and that also applies to women around the world, their diets and lifestyles. Women who suffer greatly from menopausal symptoms who consider HT are well advised to limit the duration of its use.

Environment

I’ve saved the best for the last. Dr. Eric Crighton laid it all out. There are currently 80,000 registered chemicals currently in use. 7,000 new industrial chemicals are introduced annually. Pregnant women have 43 different chemicals in their bodies.

He pointed out that some people are at higher risk than others, most notably those Indigenous people who are living with contaminated water and mercury poisoning. Of course, we are all exposed to environmental toxins. According to Health Canada’s 2010 statistics, they caused 13% of disease burden, an increased risk of prenatal and early childhood effects. He talked about pesticide exposure and its effects on the brain development of four year olds…in short, he scared the *&*^% out of his audience. I was sadly familiar with some of these issues, in particular through the Canadian Women’s Health Network.

There is good work being done by CPCHE which has published a number of useful brochures, but he pointed out that individual actions are not enough. Moreover, he said when someone is struggling, for example, to feed their family, environmental toxins are low down on their list. If you can barely afford formula, the plastic in the bottle becomes a non-issue.

I spoke with him afterwards, thanking him for mentioning the struggle of nail salon workers to limit their exposure to workplace toxins. He was aware of the work of the Toronto Healthy Nail Salon Network.

Hello from the outside. At least I can say that I’ve tried

I’m not sorry I went. I did learn a few things and have checked out a dozen links to the studies quoted. But there was little opportunity to challenge the experts or change the tone of the discourse. It does make me wonder why the SOGC invited us in the first place.

With the Canadian purchase of Sprout, the company that convinced the US Food and Drug Administration to approve flibanserin (now marketed as Addyi), Canadian approval may not be far behind. Does this medication really “even the score” with men by increasing women’s sexual desire?

But female sexuality and desire are complex. Back in 2004, a CME (continuing medical education) guide was written to help doctors integrate the “New View” approach. They included a section on the medicalization of male sexual problems and a similar history for women, including an account of the search for a female medication akin to Viagra, which had already begun by the late 1990s. The CME detailed a step by step response to this medicalization. They began by explaining that women’s sexual problems may be due to:

sociological, political or economic factors

problems relating to their partner and relationship

psychological factors

medical factors

Clearly, no medication is going to address all of these issues.

The big sell for a female equivalent to Viagra began with faulty research, which soon became medical gospel. The New View Campaign repeatedly criticized the oft quoted 43% figure, which was said to represent the total prevalence of sexual dysfunction for women 18 – 59. Where did this figure come from? The researchers, including two authors paid by Pfizer, asked 1500 women to answer “yes” or “no”, if they had experienced any of seven problems – for example, lack of desire or difficulty with lubrication – two months or more in the past year. If they answered “yes” to even one of these questions, they were popped into the sexual dysfunction category.

There is no clear biological indicator for abnormally low desire because desire is entirely subjective. In order to be diagnosed with female sexual interest/arousal disorder, one must report “significant distress” which is also highly subjective. Given the above list, what woman has not had life experiences that tamp down her desire or ability to lubricate? Just had a baby? Don’t touch me. In a loveless relationship? You don’t need lube or a pill.

There were already two failed attempts to get the FDA to approve flibanserin despite their widely publicizing the (manufactured) need for it. The FDA cited lack of effectiveness (4.4 satisfying sexual experiences vs. 3.7 for women taking a placebo: a whopping difference of 0.8%). There was also concern about side effects (e.g., dizziness, nausea, fatigue, insomnia). In fact, many women discontinued participation in the clinical trials because of these side effects. And for women who like a glass of wine before sex, forget about it. Flibanserin’s concentration – and accompanying side effects – increases with alcohol. There is a similar increase if she is using oral contraceptives or other common medications. Moreover, a woman would have to take a daily pill without expecting any change for weeks, as is the case with anti-depressants.

The third attempt was preceded by the creation of Even the Score (http://eventhescore.org/the-problem/), backed by pharmaceutical companies – a brilliant marketing ploy. They argued that medical sexism was withholding medication from women whose sexual desire was perceived as less important than men’s. Co-opting feminism is an old game, but one which, in this case, was very effective. They won the American round.